|Currently, the treatment options available for BPH include:
- Watchful waiting
- Transurethral resection (TURP)
- Transurethral microwave thermal therapy (TUMT)
- Transurethral needle ablation (TUNA®)
- Visual laser ablation of the prostate (VLAP)
- Holmium:YAG laser enucleation and ablation of the prostate (HoLEP and HoLAP)
Advantages and Disadvantages: Taking medication is simple and does not require surgery. However, drugs must be taken once or twice a day for the rest of your life. Over time, the cost can become a large expense. Common side effects can include fatigue, headache, dizziness, and impotence. Additionally, drug therapy can improve symptoms yet bladder function may deteriorate, silently leading to chronic obstructive changes with poor response to eventual prostate surgery (TURP etc.).
TRANSURETHRAL RESECTION OF THE PROSTATE (TURP)
The risks and complications associated with TURP include and are not limited to: post-operative hemorrhage, TUR-Syndrome, urinary tract infection, incontinence, impotence, retrograde ejaculation, bladder neck contractures and urethral strictures. In light of these risks, patients often shy away from TURP procedures and expose themselves to a life of watchful waiting.
Advantages and Disadvantages: TURP surgery is typically very successful in treating obstructive prostate. However, it does require general or spinal anesthesia. Moreover, patients are expected to stay in the hospital for one to five days. Recovery time is slow and patients usually do not return to normal activity for four to six weeks after treatment. Surgery does involve additional risks including the possibility of postoperative pain, discomfort and bleeding, urinary incontinence, retrograde ejaculation, impotence and rarely, death.
Transurethral Microwave Procedures
Advantages and Disadvantages: TUMT can be performed in a 1- to 2-hour office visit without IV sedation. Most patients obtain symptomatic relief of lower urinary tract symptoms in 3-4 weeks. Because patients presenting with urinary retention generally are older, have a larger prostate volume, and have more renal insufficiency, they are generally not considered candidates for TUMT. TUMT is not effective for patients with urinary retention, large median lobes or very large prostates and results in lower urinary flow patterns and higher post-void residual volumes than TURP. Complications include: transient dysuria, transient urinary retention and urinary tract infections. A variety of other rare complications following TUMT may occur. This includes, but is not limited to: urethrorectal fistula, bladder perforation and penile necrosis.
Transurethral Needle Ablation
Advantages and Disadvantages: The TUNA procedure can be performed in an office or hospital outpatient center in less than 1 hour using minimal anesthesia. Most patients obtain symptomatic relief of lower urinary tract symptoms in anywhere from 3-12 weeks. Catheterization is needed in about 40% of the patients–on average less than 2 days. Most patients are able to return to their normal activities within 24 hours. There are minimal side effects, including a few reports of sexual dysfunction. Similar to the TUMT procedure, the TUNA procedure produces insignificant changes in prostate size. In addition, there exists a disproportionate improvement of subjective results as compared with objective parameters. The TUNA and TUMT procedures do not create significant anatomic debulking, and improvement in peak flow rates, post void residual volumes and maximum detrusor pressures is less pronounced than after anatomic debulking procedures such as TURP. However, the improvement in the voiding symptoms matches that of TURP. Complications include: transient dysuria, transient urinary retention and urinary tract infections.
VISUAL LASER ABLATION OF THE PROSTATE
Advantages and Disadvantages: The coagulation effect of the Nd:YAG laser largely avoids bleeding making VLAP suitable for the treatment of patients under anticoagulant medication. Moreover, sealing of the blood vessels prevents fluid re-absorption. Application of the VLAP procedure is generally limited to prostate volumes of less then 30 ml because of a low ablation efficiency of the Nd:YAG laser. Need of postoperative catheterization increases the risk of urinary tract infection. Long lasting irritative symptoms and slow improvement of urodynamic performance after the treatment limit the acceptance of the VLAP technique. The long term improvement of AUA symptom scores are comparable to TURP whereas the improvement in maximum flow rate falls behind that of TURP and other minimally invasive procedures
HOLMIUM LASER ABLATION OF THE PROSTATE
Advantages and Disadvantages: The HoLEP technique can be used to successfully treat large prostate glands with immediate reduction of prostatic TRUS volume. The coagulative effect of Ho:YAG laser radiation offers the advantage of a reduced need for blood transfusion and less risk of fluid re-absorption.
A major disadvantage with the HoLEP technique is the high learning curve. The surgeon must perform an estimated 20-25 procedures in a short period of time to gain proficiency. Because this hurdle is often hard to make, many surgeons shy away from the HoLEP procedure. Prostate perforations were commonly experienced by surgeons during their first couple of cases or even over an extended period of time when the technique was infrequently practiced, demonstrating the need for a stringent training regime.
Another disadvantage is the increased operative time associated with the enucleation technique, which is due to the need to cut the larger pieces of tissue into smaller pieces to facilitate their removal from the bladder. This requirement previously restricted the use of HoLEP mainly to cases involving smaller prostate glands. The development of special tissue morcellators enabled some shortening of the operative time but added another expensive piece of equipment mandatory to successfully manage the procedure.